Lumb K J, Colquhoun P H D, Malthaner R A, Jayaraman S
University of Western Ontario, Department of Surgery, 339 Windermere Rd. Rm C8-114, London, Ontario, Canada.
Cochrane Database Syst Rev. 2006 Oct 18;2006(4):CD005393. doi: 10.1002/14651858.CD005393.pub2.
Hemorrhoids are one of the most common anorectal disorders. The Milligan‐Morgan open hemorrhoidectomy is the most widely practiced surgical technique used for the management of hemorrhoids and is considered the current "gold standard". Circular stapled hemorrhoidopexy was first described by Longo in 1998 as alternative to conventional excisional hemorrhoidectomy. Early, small randomized‐controlled trials comparing stapled hemorrhoidopexy with traditional excisional surgery have shown it to be less painful and that it is associated with quicker recovery. The reports also suggest a better patient acceptance and a higher compliance with day‐case procedures potentially making it more economical. A previous Cochrane Review of stapled hemorrhoidopexy and conventional excisional surgery has shown that the stapled technique is associated with a higher risk of recurrent hemorrhoids and some symptoms in long term follow‐up. Since this initial review, several more randomized controlled trials have been published that may shed more light on the differences between the novel stapled approach and conventional excisional techniques.
This review compares the use of circular stapling devices and conventional excisional techniques in the surgical treatment of hemorrhoids. Its goal is to ascertain whether there is any difference in the outcomes of the two techniques in patients with symptomatic hemorrhoids.
We searched all the major electronic databases (MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1998 to December 2009.
All randomized controlled trials comparing stapled hemorrhoidopexy to conventional excisional hemorrhoidal surgeries with a minimum follow‐up period of 6 months were included.
Data were collected on a data sheet. When appropriate, an Odds Ratio was generated using a random effects model.
Patients with SH were significantly more likely to have recurrent hemorrhoids in long term follow up at all time points than those with CH (12 trials, 955 patients, OR 3.22, CI 1.59‐6.51, p=0.001). There were 37 recurrences out of 479 patients in the stapled group versus only 9 out of 476 patients in the conventional group. Similarly, in trials where there was follow up of one year or more, SH was associated with a greater proportion of patients with hemorrhoid recurrence (5 trials, 417 patients, OR 3.60, CI 1.24‐10.49, p=0.02). Furthermore, a significantly higher proportion of patients with SH complained of the symptom of prolapse at all time points (13 studies, 1191 patients, OR 2.65, CI 1.45‐4.85, p=0.002). In studies with follow up of greater than one year, the same significant outcome was found (7 studies, 668 patients, OR 3.14, CI 1.20‐8.22, p=0.02). Patients undergoing SH were more likely to require an additional operative procedure compared to those who underwent CH (8 papers, 553 patients, OR 2.75, CI 1.31‐5.77, p=0.008). When all symptoms were considered, patients undergoing CH surgery were more likely to be asymptomatic (12 trials, 1097 patients, OR 0.59, CI 0.40‐0.88). Non significant trends in favor of SH were seen in pain, pruritis ani, and fecal urgency. All other clinical parameters showed trends favoring CH.
痔疮是最常见的肛肠疾病之一。Milligan-Morgan开放式痔切除术是治疗痔疮应用最广泛的外科技术，被认为是当前的“金标准”。吻合器痔上黏膜环切术于1998年由Longo首次描述，作为传统切除性痔切除术的替代方法。早期比较吻合器痔上黏膜环切术与传统切除手术的小型随机对照试验表明，该手术疼痛较轻，恢复较快。报告还显示患者接受度更高，对日间手术的依从性更高，可能使其更具经济性。Cochrane之前对吻合器痔上黏膜环切术和传统切除手术的综述表明，在长期随访中，吻合器技术复发性痔疮风险较高，且存在一些症状。自该初步综述以来，又发表了几项随机对照试验，可能会更清楚地揭示新型吻合器方法与传统切除技术之间的差异。
本综述比较了吻合器痔上黏膜环切术和传统切除技术在痔疮手术治疗中的应用。其目的是确定这两种技术在有症状痔疮患者中的疗效是否存在差异。
我们检索了所有主要电子数据库（MEDLINE、EMBASE和Cochrane对照试验中心注册库（CENTRAL），时间范围为1998年至2009年12月。
纳入所有比较吻合器痔上黏膜环切术与传统切除性痔手术且随访期至少6个月的随机对照试验。
数据收集在数据表上。在适当情况下，使用随机效应模型生成比值比。
在所有时间点的长期随访中，吻合器痔上黏膜环切术患者复发性痔疮的可能性显著高于传统切除手术患者（12项试验，955例患者，比值比3.22，可信区间1.59 - 6.51，p = 0.001）。吻合器组479例患者中有37例复发，而传统组476例患者中仅9例复发。同样，在随访一年或更长时间的试验中，吻合器痔上黏膜环切术患者痔疮复发的比例更高（5项试验，417例患者，比值比3.60，可信区间1.24 - 10.49，p = 0.02）。此外，在所有时间点，吻合器痔上黏膜环切术患者脱垂症状的抱怨比例显著更高（13项研究，1191例患者，比值比2.65，可信区间1.45 - 4.85，p = 0.002）。在随访超过一年的研究中，也发现了相同的显著结果（7项研究，668例患者，比值比3.14，可信区间1.20 - 8.22，p = 0.02）。与接受传统切除手术的患者相比，接受吻合器痔上黏膜环切术的患者更有可能需要额外的手术（8篇论文，553例患者，比值比2.75，可信区间1.31 - 5.77，p = 0.008）。当考虑所有症状时，接受传统切除手术的患者更有可能无症状（12项试验，1097例患者，比值比0.59，可信区间0.40 - 0.88）。在疼痛、肛门瘙痒和便急方面，有倾向于吻合器痔上黏膜环切术的不显著趋势。所有其他临床参数显示出倾向于传统切除手术的趋势。
